TOPLINE:

Surgeons in Maryland reported high awareness of the state’s All-Payer Model, in which public and private insurers pay the same price for hospital procedures to help control costs and improve patient care. They agreed that the model centralized complex care but had limited impact on clinical decision-making.

METHODOLOGY:

• Maryland’s All-Payer Model, launched in 2014, started as a global budget revenue model fixing hospital budgets to improve healthcare outcomes; the model was expanded in 2019 to cover total healthcare spending across all payers.
• Researchers used a convergent mixed-methods design to assess surgeons’ experiences with Maryland’s All-Payer Model, including the global budget revenue and total cost of care initiatives.
• A 23-item survey was distributed through major health systems in Maryland, including The Johns Hopkins Hospital, University of Maryland Medical Center, and MedStar Health. A five-point Likert scale was used to gauge responses, ranging from strongly agree to strongly disagree.
• Of the 121 surgeons who received the survey, 103 responded (65.0% men; 69.9% White individuals; mean practice duration, 16.4 years), and 25 qualitative interviews were conducted via videoconferencing to gather in-depth insights.

TAKEAWAY:

• Most surgeons (71.5%) agreed or strongly agreed that they understood how Maryland’s All-Payer Model affected patient care; 77.2% and 87.5% agreed or strongly agreed that they understood the model’s impact on their practice and its purpose, respectively. Only 38.8% of surgeons remembered receiving information about the All-Payer Model from their institutions, and 46.6% received it from discussions with peers.
• Many surgeons (59.1%) agreed or strongly agreed that implementation of the model resulted in the centralization of complex surgical care; however, fewer believed it helped with managing referrals (17.0%) or reducing preventable hospital use (18.2%).
• About half of surgeons agreed or strongly agreed that efforts were made to reduce unplanned readmissions (51.1%) and the length of hospital stay (52.3%), and 42.0% agreed or strongly agreed that a noticeable effort was made to decrease complications.
• Surgeons reported that communication gaps negatively affected their work experience, with no coordinated effort to involve them in the model’s design or provide necessary information.
• Despite increased awareness of hospital-level metrics, most surgeons found that these factors had limited influence on their clinical decision-making, with reimbursement still linked to fee-for-service models.

IN PRACTICE:

“Our findings suggested that while surgeons were broadly aware of the APM’s [All-Payer Model] cost-containment goals, substantial gaps remained in institutional communication, incentive alignment, and support for clinician engagement. Policymakers may perceive a limited need to engage surgeons in payment reform; however, institutional incentives under the APM indirectly shape surgical delivery. Reasons to engage surgeons are to ensure the sustainability of quality gains and cost savings and to mitigate and solve unintended consequences (eg, centralization, site of care optimization),” the authors of the study wrote.

SOURCE:

This study was led by Ronnie L. Shammas, MD, MPH, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York City. It was published online on January 07, 2026, in JAMA Network Open.

LIMITATIONS:

The imbalance of academic surgeons in this study may have affected the findings, and community surgeons might have different experiences. The effect of the All-Payer Model on other specialties, such as primary care physicians and hospitalists — who may be affected by hospital-level metrics — may not be fully captured.

DISCLOSURES:

This study was supported by grants from Chesapeake Regional Information System for our Patients (CRISP) to an author and partially funded by a National Cancer Institute Cancer Center Support Grant. CRISP and the Maryland Healthcare Commission were involved in designing the survey and interview guide. Some authors reported receiving grants during the conduct of the study and receiving personal fees, royalties, or contracts, outside the submitted work. One author reported having an unpaid advisory role.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.